Tuesday, August 3, 2010

I doubt whether we can draft assisted suicide legislation that is safe for human beings, with their full variety of situations.

I was going through my email this morning and came across a very good article by Onora O'Neill that was published in the Guardian newspaper on July 30, 2010. Her letter is titled: Real life is too complex, refering to - too complex to legalise assisted suicide without having colateral damage. I agree with her perspective completely. I oppose assisted suicide in order to protect others.

Real life is too complex

I doubt whether we can draft assisted suicide legislation that is safe for human beings, with their full variety of situations.

When and why should we respect individual autonomy? Does respect for individual autonomy demand a minimal state that legislates sparingly in order not to infringe individual autonomy, and in particular does not regulate action "between consenting adults"? The answers we give to these questions raise difficulties for any attempt to legalise assisted suicide.

If autonomy is taken minimally as a matter of sheer choice, then a claim that assisted suicide should be legalised in order to respect individual autonomy would mean that any choice to die – even one that reflects momentary whim, clinical depression, false beliefs, or deference to others – should be respected. I doubt whether such positions have serious supporters.

But if autonomy is not taken minimally and is not equated with sheer choice, then legislation to make assisted suicide lawful can only be justified by showing why some specific non-minimal conception of individual autonomy should command attention and respect and be enshrined in legislation.

This I think has been recognised in part in the bills to legalise assisted suicide that have come before and been rejected by the House of Lords. These bills typically have sought to include what are spoken of as "safeguards" to ensure that a choice to die indeed reflects more than a minimal conception of individual autonomy, that might reflect momentary desire, lack of comprehension or lack of information. The difficulties lie in specifying clearly the form or degree of individual autonomy that should be required for this irrevocable choice to be lawful.

Incorporating a few "safeguards" into legislation cannot, I believe, address the real difficulty of protecting patients (or others) against the consequences of choices that are not well grounded being visited upon them. A convincing non-minimalist account of individual autonomy has to take account of many ways in which individual autonomy may be limited. And here I believe our debates remain wholly inadequate.

Much popular coverage of assisted suicide has been marred by reliance on two assumptions that obstruct clear thinking.

The first assumption is a tendency to think mainly about individual cases that are so miserable that we are tempted to feel that anything must be an improvement. But of course legislation has to be framed to be safe for all citizens, not tailored for hard cases while risking the lives of others. Unless we can reliably specify the cases for which the legislation is intended, it will not be feasible to legislate. We can only legislate safely if we can reliably pick out the adequately autonomous patient (whatever that may mean) from patients whose choice is not adequately autonomous. Thinking about hard cases is not enough unless we can find clear distinctions between those cases and others.

A second assumption which mars these debates is that the image of the autonomous patient is often coupled with another stereotypical figure, namely the wholly compassionate relative, friend, carer or physician. But realities are more complex. Even the most loving families and friends may be greatly burdened by caring for a very ill person, not to mention impoverished. Even compassionate professionals are unlikely to be wholly compassionate. Compassion is often and understandably mixed with frustration and even anger, and even with hopes and interests in another's death.

How are we to tell which requests for help to commit suicide express robust individual autonomy and which do not? How can we tell which choices express compliance with the (spoken or unspoken) desires of burdened carers and relatives, or of expectant heirs, whose compassion may be limited? How we to tell which families and professionals are "wholly compassionate"?

If we are to draft safe legislation to make assisted suicide lawful we would need to distinguish and disallow requests for help that reflect either momentary despair or clinical depression, or weary compliance with, indeed deference to, the desires of relatives, carers, and professionals. Even deferential and frightened choices are choices, so minimally autonomous.

In a world of idealised wholly autonomous patients, and of wholly selfless and compassionate families and professionals, legislation providing for assisted dying might, if ethically acceptable, not be risky. But we do not live in that world, and I doubt whether we can draft legislation that is safe for human beings with their full variety of situations and dependence on one another. The philosopher Bernard Williams was, I think, right to suggest that "we should not put too much weight on the fragile structure of the voluntary".